Syfte och frågeställningar Studiens syfte var att undersöka om utförandet av en isometrisk bålstabiliseringsövning/coreövning kunde påverka upplevelsen av smärta i nacke, axlar och skuldror hos kvinnor med kronisk/långvarig idiopatisk smärta. Studiens frågeställningar var: Hur påverkar utförandet av övningen ”plankan” upplevelsen av smärta i nacke, axlar och skuldror hos deltagarna? Förändras den maximala uthålligheten i övningen mellan deltagarnas första och sista träningstillfälle? Kan interventionen fullföljas av deltagarna? Metod Fyra kvinnliga deltagare som alla hade kronisk/långvarig smärta i nacke, axlar eller skuldror utförde övningen ”plankan” som hemträningsövning under fyra veckors tid. Mängden träning dokumenterades i en träningsdagbok som deltagarna kontinuerligt fyllde i under träningsperioden. Före samt inom en vecka efter träningsperioden ifylldes en enkät med frågor om upplevd intensitet, frekvens och lokalisation av smärta. Dessutom mättes maximal uthållighet i övningen ”plankan”. Resultat Efter träningsperioden uppskattade alla deltagare med smärta i nacken en förbättring med 1-3 skalsteg i en sammanslagning av alla frågor rörande smärta i nacke. Detta innebar att förändringen mellan deltagarnas svar i före- och efterenkäten, där skalan 0-10 användes, slogs samman till ett värde. Smärta i axlarna skattades som markant förbättrad av två deltagare samt som något försämrad respektive inte förändrad av två deltagare. Endast en deltagare uppskattade sig ha smärta i skuldrorna och ingen skillnad i uppskattningen sågs mellan före- och efterenkäten. Maximal uthållighet i övningen mellan första och sista träningstillfället ökade statistiskt signifikant för alla deltagare mätt i både procent och sekunder. Slutsats Resultatet i studien tyder på att övningen kan genomföras av individer med långvarig idiopatisk smärta i nacke, axlar och skuldror utan att ökad upplevd smärta eller andra obehag uppstår samt att den maximala uthålligheten i övningen ökar genom att övningen utförs. Hur många gånger övningen måste utföras för att ge resultat på uthållighet är oklart. Trots att flera deltagare upplevde minskad smärta efter träningsperioden så kan inga slutsatser tas då deltagarantalet var litet och resultatet för interventionsgruppen inte jämförts med en kontrollgrupp. Stora variationer i utförandet av hemträningen förekom bland deltagarna och flera faktorer utöver träningsövningen kan ha påverkat förändringen i smärtupplevelse.

Background Adolescent subjective health and mental problems have become a public health concern not only in Sweden but worldwide. The overall aim of this thesis is to deepen and widen the understanding of young peoples’ subjective health, psychosomatic and stress-related problems. A special focus is put on experienced stress among adolescent girls and young women. The study setting is one youth health centre, and three upper secondary schools in Umeå, a university town in northern Sweden. The research design combines qualitative and quantitative methods with the main focus on qualitative methods. An interdisciplinary theoretical synthesis is utilised, primarily based on bio-psycho-social, phenomenological, and social constructionist approaches. The three qualitative papers (I-III) are based on the same sample of 40 young women who had sought help at the youth health centre because of their stress-related problems. Paper I explores the stressors experienced by the young women, whereas Paper II explores the lived experiences of stress. Paper III examines the young women’s experiences of living in a violent partner relationship as young teenagers, and how this has affected their lives and health over time. Paper IV investigates perceived stress and subjective health complaints among older adolescents in upper secondary school.   Methods Data was derived from: a) a qualitative interview study with 40 adolescent girls and young women, aged between 16–25 years, who had sought help at the youth health centre for stress problems. Qualitative content analysis was used in combination with discourse-orientated analysis (Paper I); a phenomenological approach (Paper II), and narrative method (Paper III); b) a school-based survey with a sample of 16–18-year-old boys and girls (n=1027), in upper secondary school, grades 1 and 2, from different educational programs at three schools. Perceived stress, self-rated health, subjective health complaints, anxiety, and depression, were measured with a questionnaire including a set of instruments. Statistical analyses were descriptive and analytical.   Results Paper I identified multiple stressors of modernity, gender orders and youth. Contextual factors, including social constructions and practices of gender, played an important role for the stress experienced by these young women. The results revealed that multiple and intersecting stressors and demands connected to essential life spheres, contributed not only to experiences of distress but also to feelings of constraint. Moreover, the roles of excessive taking of responsibility and failing adult support were revealed. Paper II illuminated multidimensional lived and embodied experiences of distress. ‘Living close to the edge’ emerged as the common theme running through all of the interviews and captured the young women’s sometimes unbearable situations. The theme contains dimensions of physical, emotional, cognitive, social, and existential distress, as well as dimensions of distrust and disempowerment. Paper III examined two Swedish adolescent girls’ experiences of living in a violent relationship as teenagers, and how this has affected their lives and health over time. The analysis revealed violation, stress, trauma, coping, and agency during adolescence and the transition into adulthood. Paper IV showed a high level of perceived stress, and subjective health and stress complaints among boys and girls. High pressure and excessive demands from school were experienced by a majority of boys and girls. Perceived stress was correlated with subjective health and stress complaints and anxiety. There was a clear gender difference: two to three times as many girls than boys reported subjective health complaints, e.g. headaches, tiredness and sleeping difficulties, musculoskeletal pain, sadness and anxiety.   Conclusion Several issues of relevance to public health were raised throughout the thesis. According to the interview results, the young women face multiple and intersecting stressors of modernity, gender orders and being young, which correspond to their multidimensional experiences of ‘living close to the edge’. Their experiences of stress are multidimensional, and include physical, emotional, cognitive, social and existential dimensions. Findings from the qualitative study were also mirrored in the findings from the larger group of adolescents in the school survey, where a high proportion of older adolescents, particularly girls, reported perceptions of stress. Moreover, perceived stress correlated to a variety of subjective health complaints and anxiety. The results can be understood and explained from a variety of perspectives. The experience of ‘managing alone’ indicated perceptions of inadequate social support. The overall results indicated a risk of more negative health development, particularly among adolescent girls and young women. Stressors of modernity, gender orders and youth were prominent. The continuation and normalisation of oppression and violence are also discussed as a severe gendered stressor in young women’s lives. This calls for a broad contextualised and gender-sensitive approach to young people’s stress and health problems. In conclusion, the age and gender gap in adolescent health needs to be further explored, and processes of distress, distrust and disempowerment have to be taken more seriously. / Under det senaste decenniet har medier och flertalet nationella forskningsrapporter informerat om ökande psykisk ohälsa och stress bland barn och unga i Sverige. Denna avhandlings syfte är att med hjälp av en utforskande och tvärvetenskaplig ansats fördjupa förståelsen av subjektiva ohälsoproblem och upplevd stress bland unga i Sverige, med speciellt fokus på flickors och unga kvinnors upplevda stressproblem. Avhandlingen har en explorativ och flexibel studiedesign som kombinerar kvalitativa och kvantitativa forskningsmetoder med särskild tyngdpunkt på de kvalitativa metoderna. Datainsamling har genomförts med a) kvalitativa forskningsintervjuer med en grupp flickor och unga kvinnor (16–25 år) som sökt hjälp för stressrelaterade problem på en ungdomshälsomottagning i Umeå, och b) en skolbaserad enkätunder-sökning med totalt 1027 pojkar och flickor, 16–18 år, i åk 1–2 på tre kommunala gymnasieskolor i Umeå. Forskningsintervjuerna har huvudsakligen analyserats med kvalitativ innehållsanalys. Innehållsanalysen har i de olika delarbetena sedan kombinerats med diskursorienterad analys (Artikel I), med fenomenologisk ansats (Artikel II) och med narrativ metod (Artikel III). Skolenkäten har analyserats med deskriptiva och analytiska statistiska metoder (Artikel IV). Resultaten från den kvalitativa intervjuundersökningen med unga kvinnor belyser a) multipla stressorer som kan hänföras till flera parallella områden i livet – men även till samhälleliga diskurser: modernitetens stressorer, genusordningarnas stressorer och ungdoms-årens stressorer, b) multidimensionella, levda och förkroppsligade erfarenheter av stress och ”att leva på gränsen” som innefattar fysiska, emotionella, kognitiva, sociala och existentiella dimensioner och c) erfarenheter av våld och kontroll i partnerrelationer samt deras konsekvenser. Resultaten från enkätundersökningen med gymnasielever visar att en stor andel av ungdomarna rapporterar subjektiva hälso- och stressbesvär av olika slag inklusive oro och ångest. Jämfört med pojkarna så är det två till tre gånger fler flickor som rapporterar besvär och denna skillnad är signifikant. En majoritet av ungdomarna håller ett högt tempo och upplever sig också pressade av krav från skolan samt av egna inre krav. Upplevelserna av stress i form av högt tempo och höga krav korrelerar med de subjektiva hälso- och stressbesvären samt med ångest.   Sammanfattningsvis visar avhandlingen att ungas stressrelaterade och subjektiva hälsobesvär bör förstås i ett vidare socialt sammanhang som inkluderar ett genusperspektiv. Kontext- och genusspecifika interventionsmodeller behöver utvecklas för att möta dessa hälsoproblem, men stress bland unga behöver också diskuteras och studeras vidare i relation till hur samhällsutvecklingen och dess värdegrunder påverkar unga av idag.

Dietary fat quality influences the risk of type 2 diabetes and cardiovascular disease. A low-grade inflammation is suggested to contribute to the disease development, often accompanied by obesity. Whereas n-3 polyunsaturated fatty acids (PUFA) have been considered anti-inflammatory, n-6 PUFA have been proposed to act pro-inflammatory. Saturated fatty acids (SFA) act pro-inflammatory in vitro. This thesis aimed to investigate effects of different fatty acids on low-grade inflammation in observational and interventional studies. In Paper I and II, fatty acid composition in serum cholesterol esters was used as objective marker of dietary fat quality and related to serum C-reactive protein (CRP) and other circulating inflammatory markers in two population-based cohorts, conducted in middle-aged men and elderly men and women, respectively. In Paper III and IV, the impact of diets differing in fat quality on inflammation and oxidative stress was investigated in randomised controlled studies, in subjects with metabolic syndrome and abdominal obesity. In Paper I and II, a low proportion of linoleic acid (18:2 n-6) in serum was associated with higher CRP concentrations, indicating that a low intake of vegetable fats may be related to low-grade inflammation. High CRP concentrations were also associated with high proportions of palmitoleic (16:1) and oleic (18:1) acids and high stearoyl coenzymeA desaturase index, possibly reflecting altered fat metabolism and/or high SFA intake in this population. When comparing two high-fat diets rich in either saturated or monounsaturated fat, and two low-fat diets with or without long-chain n-3 PUFA supplementation during 12 weeks (Paper III), no differences in inflammation or oxidative stress markers were observed. Moreover, a 10-week intervention (Paper IV) with high linoleic acid intake showed no adverse effects on inflammation or oxidative stress. Instead, interleukin-1 receptor antagonist and tumor necrosis factor receptor-2 decreased after linoleic acid intake compared with a diet high in SFA. The results in this thesis indicate that dietary n-6 PUFA found in vegetable fats is associated with lower inflammation marker levels, and to some extent reduces systemic inflammation when compared with SFA. Supplementation of n-3 PUFA did not exert any systemic anti-inflammatory effects, maybe due to a relatively low dose.

Människor med hög socioekonomisk status har bättre matvanor och är mer miljömedvetna jämfört med de individer med låg socioekonomisk status, vilket bland annat beror på högre utbildningsnivå och inkomst. För att etablera goda matvanor krävs att det finns goda förutsättningar, till exempel är tillgången till mataffärer med ett stort utbud av färskvaror associerat med hälsosamma matvanor och frånvaron av bra mataffärer påverkar framför allt utsatta grupper i samhället. Syftet med den här studien är att beskriva matvanor och miljömedvetenheten bland ungdomar och undersöka om det finns skillnader i matvanor, miljömedvetenhet och förutsättningar för goda matvanor mellan ungdomar som bor i stadsdelar med olika socioekonomisk status i Västerås. Studien har en kvantitativ ansats med en tvärsnittsdesign. Sekundära data har använts från studien Neighborhood, sustainable lifestyle and health among adolescents (NESLA), som genomfördes år 2017 på ungdomar från andra och tredje året på gymnasiet. Resultatet visar att ungdomar konsumerar frukt och grönsaker för sällan och konsumerar läsk, godis och chips för ofta. Majoriteten av ungdomarna äter på en snabbmatsrestaurang minst en gång i veckan. Nästan hälften av ungdomarna äter frukost varje dag och majoriteten av ungdomarna äter lunch i skolan varje dag. De flesta ungdomar är miljömedvetna, då majoriteten är oroliga för miljö- och klimatförändringar och tror att det är möjligt att påverka miljön genom egna livsstilsval. Det finns en signifikant korrelation mellan hög miljömedvetenhet och ohälsosamma matvanor. Det finns inga signifikanta skillnader mellan ungdomar från stadsdelar med olika socioekonomisk status och matvanor. Det finns inte heller någon skillnad mellan ungdomar från olika stadsdelar och huruvida de är oroliga för miljöförändringar, men för huruvida ungdomarna tror att de kan påverka miljön genom livsstilen. Ungdomar som bor i stadsdelar med låg socioekonomisk status rapporterar att de har bättre förutsättningar för hälsosamma matvanor jämfört med ungdomar från stadsdelar med medelhög och hög socioekonomiska status. För att diskutera resultatet har den ekologiska modellen använts som teoretiskt perspektiv. / Individuals with high socioeconomic status have better food habits and are more environmentally aware, due to higher education level and income. To establish healthy food habits, it requires that there are good prerequisites such as food stores with a wide range of fresh food since it is associated with healthy food habits of an individual and absence of good food stores is mainly affecting disadvantaged groups. The aim of this study is to describe food habits and environmental awareness among adolescents in Västerås and investigate if there are differences regarding food habits, environmental awareness and prerequisites for healthy food habits between adolescents living in neighborhoods with different socioeconomic status. The study is a quantitative study with a cross-sectional study design. Secondary data was used from the study Neighborhood, sustainable lifestyle and health among adolescents (NESLA), which was conducted in autumn of 2017 on adolescents from year two and three in high school. The result shows that the adolescents’ have a low consumption of fruits and vegetables and a high consumption of candy, chips, other snacks and soda. The majority of the adolescents’ eats at a fast food restaurant at least once a week. Almost half of the adolescents’ eats breakfast every day and the majority eats lunch at school every day a regular week. Most of the adolescents are environmentally aware, since they are worried about environmental issues and climate changes and believe that their lifestyle choices can affect the environment. A significant correlation between high environmental awareness and unhealthy food habits is found. There is no statistically significant difference between neighborhood-level socioeconomic status and food habits, and for being worried about environmental issues and climate changes. Significant differences are found between adolescents from neighborhoods with different socioeconomic status and believing in that lifestyle choices affects the environment. Adolescents living in low socioeconomic status neighborhoods reported that they have greater prerequisites for healthy food habits compared to middle-high and high socioeconomic status neighborhoods. The ecological model was used as a theoretical perspective to discuss the results.

Sammanfattning Syfte och frågeställningar Syftet med studien var att få en inblick i hur omfattande smartphoneanvändning var bland människor och hur denna användning samvarierade med den mentala hälsan. En annan del av syftet var att se om ett beteendemönster kunde ändras hos smartphoneanvändarna och på så vis ändra den mentala hälsan. För att uppnå syftet ställdes två frågeställningar: (1) Finns det något samband mellan grad av smartphoneberoende och upplevd psykisk hälsa? (2) Kan en kortare tids intervention där man begränsar användandet av smartphone hos deltagarna påverka deras subjektiva psykiska välmående? Metod För att få en inblick i hur utbrett smartphoneberoendet är i dagsläget och om det påverkar den subjektiva psykiska hälsan valdes enkät som metod eftersom det var tidseffektivt och gav ett brett urval. För att kunna skapa en beteendeförändring så behövdes en aktiv interaktion med respondenterna, därför kom beslutet att utföra en intervention. Interventionen gick ut på att deltagarna under sex dagar skulle reducera sitt mobilanvändande i största mån möjligt för att se om deras mentala hälsa kunde påverkas. Urvalet bestod av 76 kvinnor och 56 män med en medelålder på 25 år. Resultat Enligt korrelationsanalysen fanns ett svagt samband r = - 0,218 mellan mental hälsa och smartphoneberoende som var statistiskt signifikant (p = 0.013). Analys av enkätdata visade en stor grupp som klassades som smartphoneberoende = 48.2% och 51.8% som ej smartphoneberoende. Detta visade att fler personer är mobilberoende i detta urval än vad andra studier hittat. Interventionen bortgick på grund av ett stort bortfall. Slutsats Resultatet visade på ett svagt negativt samband mellan mental hälsa och smartphoneberoende. Kausalitetssamband klargjordes inte och vidare forskning krävs på ämnet för att i framtiden kunna urskilja om en mental ohälsa leder till mer smartphoneanvändande eller om mycket smartphoneanvändning leder till mental ohälsa i sig. / Abstract Purpose and objective The purpose of this study was to survey the use of mobile phones amongst people and how it coincides with mental health. We also wanted to investigate whether or not we could create a behavioral change amongst the mobile phone users and thereby see if it affected their mental health. To achieve this objective we emanated from two questions: (1) Is there a relationship between Smartphone addiction and subjective mental health? (2) Can a short intervention, where you decrease the time spent on smartphones amongst users improve their subjective well-being? Method To get an insight in how widespread the use of mobile phones is and if it affects subjective well-being we chose to collect data through surveys because it was time effective and gave a wide group of people. To be able to create a behavioral change we concluded we had to actively interact with the respondents, so we chose to perform an intervention. During the intervention the participants would reduce their mobile phone usage to the greatest extent possible to see if their mental health could be improved. Result According to the correlation analysis, there is a weak relationship r = - 0,218 between mental health and smartphone addiction which is statistically significant (p=0.013). Analysis of survey data showed a large group classified as smartphone addicted = 48.2% and 51.8% as non-smartphone addicted. This shows that more people are smartphone addicted in this study than other studies have found. The intervention failed due to many dropouts. Conclusions The result showed a weak negative correlation between mental health and smartphone addiction. Causal correlation was not clarified and further research is required on the subject in order to determine whether mental health issues leads to more smartphone usage or if a lot of smartphone usage leads to mental health issues by itself.

Menstrual management is a pervasive issue for women globally, and it becomes critical in times of crisis. During these times of crisis and disaster, humanitarian response seeks to provide relief of suffering by meeting essential needs, in a comprehensive and predictable manner. Yet the provision of menstrual management remains largely ad hoc. Through a comprehensive literature review of documents pertaining to menstrual management in emergencies, this paper offers a qualitative analysis of modern humanitarian strategic approaches, to explore the place of menstrual management in emergencies. The core findings are that menstrual management is not fodder for strategy in humanitarian aid, and therefore lacks a ‘home’ in any of the humanitarian approaches to response. It is not fully integrated into either technical strategic implementation, typified by the cluster approach, nor through cultural implementation approaches, typified by gender mainstreaming. This paper also offers some explanations of why such an omnipresent need has, as yet, remained un-championed. This discussion is based on a theoretical framework offered by feminist theory. Supplemented by an understanding of organisations as gendered structures (Acker, 1990), this thesis posits that these cavities in modern humanitarian response are due to the inherent inability and reluctance of the humanitarian system to concern itself with a bodily, female issue such as menstrual management.

Abstract Background. It is relatively well established in previous research that unemployment has direct health consequences in terms of mental and physical ill health. Recently, knowledge has emerged indicating that unemployment can lead to economic consequences that remain long after re-establishment in the labour market. However, few empirical studies have been able to apply a life course perspective asking whether there are also long-term health consequences of unemployment, and, when and in which context unemployment may affect the individual health status across the life course. The aim of this thesis was to analyse the relationship between unemployment and illness across the life course, and how it relates to individual and structural factors in the geographical setting of northern Sweden. In particular, three main areas have been explored: youth unemployment and illness in adulthood (Paper I and Paper II), contextual unemployment of national unemployment rate and neighbourhood unemployment (Paper II and Paper III) and lastly, social determinants of health inequality between employment statuses (Paper IV). Methods. This thesis is positioned in Sweden between the early 1980s and the mid-2010s, following two comparable cohorts sampled from northern Sweden (26 and 19 years follow-up time respectively from youth to midlife) and a cross-sectional sample from 2014 of the four northernmost counties in Sweden. The two longitudinal cohorts comprised the Northern Swedish Cohort and the Younger Northern Swedish Cohort, consisting of all pupils in the 9th grade of compulsory school in Luleå municipality in 1981 and 1989. The participants responded to an extensive questionnaire on socioeconomic factors, work and health, in 5 and 2 waves respectively of data collections. Neighbourhood register data from Statistics Sweden was also collected for all participants in the Northern Sweden Cohort. At the latest data collection, 94.3% (n=1010) participated in the Northern Sweden Cohort and 85.6% (n=686) in the Younger Northern Sweden Cohort. The cross-sectional study Health on Equal Terms is a national study, administered by the Public Health Agency together with Statistics Sweden and county councils with the aim of mapping public health and living conditions in the country over time. In this thesis, material from 2014 has been used for northern Sweden with a response rate of around 50% (effective sample n=12769). The statistical analyses used were linear regression, multilevel analysis and difference-in-difference analysis to estimate the concurrent and long-term health consequences of unemployment, and a decomposition analysis to disentangle the inequality in health between different labour market positions. The health outcomes in focus were functional somatic symptoms (the occurrence of relatively common physical illnesses such as head, muscle and stomach ache, insomnia and palpitation) and psychological distress. Results. Among men only, as little as one month of youth unemployment was related to increased levels of functional somatic symptoms in midlife, regardless of previous ill health or unemployment later in life, although only during relatively low national unemployment (pre-recession) when comparing with youth unemployment during high national unemployment (recession). This was explained by the health promoting effect of more time spent in higher education during the recession period. Furthermore, the health impact of neighbourhood unemployment highlights the importance of the contextual setting for individuals’ health both across the life course and at specific periods of life. Lastly, employment-related mental health inequalities exist for both men and women in all life phases (youth, adulthood and midlife). Economic and social deprivation related to unemployment and illness varied across different phases in life and across genders. Conclusion. The key findings of this thesis paint a rather pessimistic vision of the future: one’s own and others’ unemployment may cause not only ill health today but also ill health later in life. Importantly, the responsibility of unemployment and the associated ill health should not be placed on the already marginalised individuals and communities. Instead, the responsibility should be directed towards the structural aspects of society and the political choices that shape these. In other words, health inequality manifested by the position in the labour market is socially produced, unfair and changeable through political decisions. The results of this study therefore cannot contribute to any simple or concrete solutions to the concurrent or long-term health consequences of individual or contextual unemployment, as the solution is beyond the areas of responsibility and abilities of research. However, if there are long-term health consequences of one’s own and other people’s unemployment, labour market and public health policies should be initiated from a young age and continue throughout the life course to reduce individual suffering and future costs of social insurance, sick-leave and unemployment benefits.

Background: Lifestyle habits like tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity are risk factors for developing non-communicable diseases, which are the leading, global causes of death. Furthermore, ill health and chronic diseases are costly and put an increased burden on societies and health systems.  In order to address this situation, governmental bodies and organizations’ have encouraged healthcare providers to reorient the focus of healthcare and undertake effective interventions that support patients to engage in healthy lifestyle habits. In Sweden, national clinical practice guidelines (CPGs) on lifestyle interventions were released in 2011. However, the challenges of changing clinical practice and introducing guidelines are well documented, and health interventions face particular difficulties. The overall purpose of this thesis is to contribute towards a better understanding of the complexities of shifting primary health care to become more health oriented, and to explore the implementation environment and its effect on lifestyle intervention CPGs. The specific aims are to investigate how implementation challenges were addressed during the guideline development process (Study I), to investigate several dimensions of readiness for implementing lifestyle intervention guidelines, including aspects of the intervention and the intervention context (Study II), to explore the extent to which health care professionals are working with lifestyle interventions in primary health care, and to describe and develop a baseline measure of professional knowledge, attitudes and perceived organizational support for lifestyle interventions (Study III), and to assess the progress of implementing lifestyle interventions in primary care settings, as  well as investigate the uptake and usage of the CPGs in clinical practice (Study IV).   Methods and results: Interviews were conducted with national guideline-developers (n=7). They were aware of numerous implementation challenges, and applied strategies and ways to address them during the guideline development process. The strategies adhered to four themes: (a) broad agreements and consensus about scope and purpose, (b) systematic and active involvement of stakeholders, (c) formalized and structured development procedures, and (d) openness and transparent development procedures. At the same time, the CPGs for lifestyle interventions challenged the development-model at the National Board of Health and Welfare (NBHW) because of their preventive and non-disease specific focus (I). A multiple case study was also conducted, using a mixed methods approach to gather data from key organizational individuals that were accountable for planning the implementation of CPGs (n=10), as well as health professionals and managers (n=340). Analysis of this data revealed that conditions for change were favorable in the two organizations that served as case studies, especially concerning change focus (health orientation) and the specific intervention (national guidelines on lifestyle interventions). Somewhat limited support was found for change and learning, and change format (national guidelines in general). Furthermore, factors in the outer context were found to influence the priority and timing of the intervention, as well as considerable inconsistencies across the professional groups (II). A cross-sectional study among physicians and nurses (n=315) in Swedish primary healthcare showed that healthcare professionals have a largely positive attitude and thorough overall knowledge of lifestyle intervention methods. However, both the level of knowledge and the involvement in patients’ lifestyle change, differed between professional groups. Organizational support like CPGs and the development of primary health care (PHC) collaborations with other stakeholders were identified as potential strategies for enhancing the implementation of lifestyle interventions in PHC (III). In addition to interviews and case studies, a longitudinal survey among health professionals (n=150; n=73) demonstrated that their use of methods to encourage patients to reduce or eliminate tobacco or alcohol use, had increased. The survey also indicated that nurses had increased the extent to which they addressed all four lifestyle habits. The progress of the implementation of CPGs on lifestyle interventions in PHC was somewhat limited, and important differences in physicians and nurses’ attitudes, as well as their use of the guidelines, were found (IV). Conclusions: Health orientation differs in many ways from more traditional fields in medicine. To strengthen the implementation of this very important (but not “urgent”) field in health care, it needs, first of all, to be prioritized at all levels! The results of the studies demonstrate relatively slow adoption of lifestyle intervention CPGs in clinical practice, and indicate room for improvement. The findings of this thesis can inform healthcare policy and research on further development of the health orientation perspective, as well as on the challenges of implementing CPGs on lifestyle interventions in primary care. In summary, this thesis presents important lessons learned regarding health orientation - from the development of CPGs in the field, via assessing healthcare organizations’ readiness to change and health professionals’ attitudes to methods to support patients with lifestyle changes. / Bakgrund: Levnadsvanor som tobaksbruk, riskbruk av alkohol, ohälsosamma matvanor och otillräcklig fysisk aktivitet är riskfaktorer för att utveckla kroniska sjukdomar, vilka orsakar de flesta dödsfallen i världen. Ohälsa och dess följdsjukdomar utmanar också samhällen och hälsosystem världen över p.g.a. de höga kostnader som de medför. För att förbättra situationen så försöker regeringar och organisationer förändra hälso- och sjukvårdens perspektiv till att fokusera mer på hälsa och att arbeta med effektiva interventioner för att förebygga och att förändra människors ohälsosamma vanor. År 2011 i Sverige, publicerades nationella kliniska riktlinjer för vårdens arbete med att förebygga sjukdom genom att stödja förändring av patienters ohälsosamma levnadsvanor. Det är dock välkänt hur svårt det är att förändra klinisk praxis och att introducera riktlinjer, och interventioner på området hälsa i sjukvården brottas med specifika utmaningar. Det övergripande syftet med den här avhandlingen har varit att bidra till en bättre förståelse av komplexiteten i att hälsoorientera primärvården, och att utforska förutsättningarna till att implementera kliniska riktlinjer för att stödja förändring av patienters levnadsvanor. De mer specifika syftena var: att (I) utforska hur implementeringsutmaningarna behandlades i utvecklingsprocessen av riktlinjerna ; att (II) undersöka dimensioner av beredskapen för förändring i primärvården för att implementera riktlinjerna om levnadsvanor inkluderande aspekter av interventionen själv samt kontexten ; att (III) utforska i vilken utsträckning hälsoprofessionerna arbetar med levnadsvanor i primärvården, och att beskriva deras kunskap, attityder och uppfattat organisatoriskt stöd för livsstilsinterventioner ; att (IV) i en två-årig uppföljning utvärdera utvecklingen av arbetet med levnadsvanor i primärvården, och användningen av de specifika nationella riktlinjerna för levnadsvanor. Metod och resultat: En intervjustudie med riktlinjeutvecklare på nationell nivå (n = 7) visade att många utmaningar för implementeringen av riktlinjerna identifierades och bemöttes under utvecklingsprocessen i fyra teman av strategier: breda överenskommelser och konsensus om inriktning och syfte, systematiskt och aktivt inkluderande av stakeholders, formaliserad och strukturerad utvecklingsprocess, öppenhet och insyn utvecklingsprocess. Samtidigt utmanade dock riktlinjerna om livsstilsinterventioner Socialstyrelsens utvecklingmodell p.g.a. deras förebyggande och icke sjukdomsspecifika fokus (I). En multipel fallstudie med nyckelpersoner ansvariga för implementeringen av riktlinjerna i sjukvårdsorganisationerna (n = 10) samt vårdpersonal och chefer (n = 340), visade på gynnsamma villkor för förändring i båda organisationerna rörande förändringsfokus (d.v.s. hälsoorientering) och den specifika interventionen (d.v.s. riktlinjer om metoder för att stödja förändring av ohälsosamma levnadsvanor). Stödet för förändring och lärande visade på något svagare resultat, likaså formen för förändringen d.v.s. nationella riktlinjer i allmänhet. Faktorer i den yttre kontexten visade sig kunna påverka prioritering av och optimalt val av tidpunkt för interventionen, likaså betydande skillnader i uppfattningar mellan yrkesgrupperna (II). En tvärsnittsstudie bland läkare och sjuksköterskor (n = 315) i primärvården visade att de har en positiv attityd och en god kunskapsnivå om metoder för livsstilsförändring. Både kunskapsnivå och i vilken utsträckning man arbetar med patienters livsstil skiljer sig mellan yrkesgrupper. Organisatoriskt stöd som nationella riktlinjer och utvecklandet av primärvårdens samarbete med intressenter i närområdet identifierades som viktigt för att förbättra arbetet med livsstil interventioner (III). En longitudinell undersökning bland vårdpersonal visade att användning av metoder för att förändra patientens vanor beträffande tobaksbruk och riskbruk av alkohol har ökat över tid, och att sjuksköterskorna arbetar i högre utsträckning med alla fyra levnadsvanorna än i tidigare. Implementeringen av de nationella riktlinjerna för levnadsvanor hade inte kommit så långt vid det andra mättillfället, och stora skillnader visade sig i hur läkare och sköterskor ser på riktlinjer och i vilken utsträckning de använder dem (IV). Slutsats: Hälsofrämjande och prevention skiljer sig på många sätt från mer traditionella fält inom medicinen. För att stärka implementeringen av det här viktiga (men ej akuta) fältet i hälso- och sjukvården, så måste det först av allt prioriteras på alla nivåer! Resultatet visar på ett svagt upptag av riktlinjerna för livsstilsinterventioner i klinisk praxis, och lämnar utrymme till förbättring. Aspekter av resultatet som presenteras i avhandlingen kan vägleda fortsatt utveckling och implementering av hälsoorientering och riktlinjer för livsstilsinterventioner inom primärvården, samt användas för att påverka policy, praxis och framtida forskning. Det gäller framför allt aspekter av utveckling av nationella riktlinjer på området; hälso- och sjukvårdsorganisationernas beredskap till förändring; hälsoprofessionernas attityder, kunskap och i vilken utsträckning de arbetar med livsstilsinterventioner och riktlinjer.

Background: The military conflict in Ukraine that started in 2014 was accompanied with many changes in the political, economic and social spheres. It brought informal volunteering activities (i.e. one form of social capital) to emerge, function and later to be formalized, in order to support soldiers and their families. This situation is unique given the transitional setting of Ukraine, which has led to comparably low levels of social capital and negative indicators of health and well-being. This thesis aims to explore social capital during military conflict in contemporary Ukraine and to analyze the associations between social capital and well-being, as well as the distribution of social capital among Ukrainian women and men. Methods: The study combines a qualitative and quantitative research design. A case study was conducted using qualitative methodology. Eighteen in-depth interviews were collected with providers and utilizers of volunteering services. Grounded Theory and social action ideal types methodology of Weber were used for the analysis. The quantitative research utilized two secondary datasets. The World Health Survey was utilized to analyze the association between social capital and physical and mental well-being for women (n=1723) and men (n=910) by means of multivariate logistic regression. The European Social Survey (wave 6) was used in order to investigate access to social capital and the determinants of gender inequalities in the access with a sample of 1377 women and 797 men. Multivariate logistic regression and postregression Fairlie’s decomposition analysis were used to analyze the determinants of the inequalities. Results: The key findings of this thesis show that social capital transforms during military conflict and takes particular forms in transitional settings. There are positive and negative effects on well-being connected to crisisrelated volunteering. The associations between social capital and well-being vary for women and men in favour of women. Social capital is unequally distributed between different social groups. Some forms of social capital may have stronger buffering effect on women than men in Ukraine. Access to social capital can be viewed as an indicator for social well-being, and thus social capital can be used both as a determinant and an outcome in social capital and health research. Conclusion: Informal social participation, i.e. volunteering might play an important role in societal crises and needs to be considered in social capital measurements and interventions. Social capital measurements utilized in stable societies do not evidently capture these forms, i.e. it is not taken into account. The associations between social capital and well-being depend on the measurements that are used. Since social capital has both positive and negative effects on well-being, this should be considered in research, policies and practices in order to prevent negative and promote positive outcomes. In Ukraine, as well as in other settings, social capital is an unequal resource for different societal groups. Reducing gender and income inequalities would probably influence the distribution of social capital within the society. / Bakgrund: Den militära konflikten i Ukraina som startade 2014 fick många politiska, ekonomiska och sociala konsekvenser. Konfliktsituationen triggade bland annat framväxten av omfattande informella volontärverksamheter (en form av social kapital) som senare formaliserades, för att stödja soldater och deras familjer. Denna situation är relativt unik, med tanke på Ukrainas postsovjetiska historia med jämförelsevis låga nivåer av socialt kapital och negativa indikatorer för hälsa och välbefinnande. Denna avhandling syftar att undersöka betydelsen av socialt kapital under pågående militär konflikt i Ukraina, samt att analysera sambandet mellan social kapital och välbefinnande, såväl som fördelningen av social kapitalt mellan kvinnor och män i Ukraina. Metoder: Studien kombinerar en kvalitativ och kvantitativ forskningsdesign. En fallstudie genomfördes med hjälp av kvalitativa metoder. Arton djupintervjuer med volontärer samt mottagare av volontärstöd genomfördes. Analysen genomfördes med hjälp av Grundad Teori och Webers sociala idealtyper. Den kvantitativa forskningen är baserad på två sekundära datamaterial. Världshälsoorganisationens (WHOs) World Health Survey användes för att analysera sambandet mellan socialt kapital och fysiskt och mentalt välbefinnande för kvinnor (n = 1723) och män (n = 910) med hjälp av multivariabel logistisk regression. European Social Survey (våg 6) användes för att undersöka tillgången till socialt kapital och bestämningsfaktorer för ojämlikhet i tillgången till socialt kapital mellan kvinnor (n = 1377) och män ( n = 797). Analysen genomfördes med hjälp av multivariabel logistisk regression och post-regression Fairlie decomposition analys. Resultat: Resultaten i denna avhandling visar att social kapital transformeras under pågående militär konflikt och antar särskilda former i övergångssamhällen som Ukraina. Det finns både positiva och negativa effekter på välbefinnande relaterat till volontärarbete under pågående samhällskris. Sambanden mellan social kapital och välbefinnande varierar för kvinnor och män till förmån för kvinnor. Vissa former av socialt kapital kan ha en starkare skyddande effekt för kvinnor än män i Ukraina. Resultaten visar också att socialt kapital fördelas ojämnt mellan män och kvinnor. Tillgången till socialt kapital kan betraktas som en indikator för socialt välbefinnande och socialt kapital kan därmed användas både som determinant och ett utfall i studier om socialt kapital, hälsa och välbefinnande. Slutsats: Informellt socialt deltagande, dvs volontärarbete, kan spela en viktig roll i samhällskriser och behöver beaktas i såväl mätningar som interventioner av socialt kapital. Mätningar av socialt kapital i ”stabila” samhällen fångar nödvändigtvis inte dessa former av socialt kapital. Sambandet mellan social kapital och välbefinnande beror till stor det på vilka mått för socialt kapital som används. Eftersom socialt kapital har både positiva och negativa effekter på välbefinnande bör det tas i beaktande i forskning, policy och praxis för att kunna förhindra negativa effekter och främja de positiva effekterna. I Ukraina, liksom i andra samhällen, är socialt kapital en ojämn resurs för olika samhällsgrupper. Att minska klyftor mellan könen och inkomstgrupper skulle troligen påverka fördelningen av socialt kapital i samhället.

The overall aim of this thesis was to examine the distribution of health literacy (HL) levels in newly arrived Arabic-, Dari-, or Somali-speaking refugees in Sweden. Further aims were to investigate sociodemographic characteristics associated with inadequate HL in this group, and to investigate whether HL levels are associated with experiences of the health examination for asylum seekers (HEA), health seeking behaviour and health. Three quantitative cross-sectional studies, using data from two different surveys, were conducted among Arabic-, Dari-, and Somali-speaking, newly arrived refugees taking part in courses in Swedish for immigrants or civic orientation. In addition, an explorative qualitative study, based on focus group discussions, was performed on Arabic- and Somali-speaking newly arrived refugees who had taken part in an HEA. All data were collected 2013-2016. The quantitative data were analysed using different statistical methods, foremost descriptive statistics and univariate and multivariate binary logistic regression analyses. The qualitative data were analysed using Graneheim and Lundman’s method for latent content analysis. The main findings were that the majority of Arabic-, Dari-, or Somali-speaking refugees in Sweden have limited functional health literacy (FHL) and/or limited comprehensive health literacy (CHL). Having a low education level and/or being born in Somalia were associated with having inadequate FHL, but not with having inadequate CHL. Limited FHL was associated with inadequate CHL. Experiences of poor quality of communication and having benefited little from the HEA were more common among those with limited CHL, as compared to those with higher CHL. Experiences of communication problems and a lack of information related to the HEA were found in the qualitative studies as well. In addition, it was more common that those with limited CHL reported poor general health and impaired psychological well-being, and that they had refrained from seeking healthcare. In conclusion: limited HL is common among newly arrived refugees in Sweden and seems to be of importance for the experience of the HEA, health-seeking behaviour and health. HL needs to be taken into consideration in the work with refugees in order to increase equity in healthcare and health.